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Biomedical subjects

R J Mullins

Publications and source records attributed to R J Mullins.

At least 19 recordsLinked to original sources
PubMed1998

Adequacy of hospital discharge status as a measure of outcome among injured patients.

CONTEXT: Crude mortality rates at the time of hospital discharge are commonly used to assess the quality of care provided to patients hospitalized following trauma. OBJECTIVES: To evaluate the adequacy of hospital death rates as an outcome measure following trauma and to determine the influence of noninjury illness as a cause of hospital death and the frequency of postdischarge death. DESIGN: Retrospective cohort analyses using hospital discharge data for injured patients cross-linked to death certificate data that provided 1 year of follow-up for all patients discharged alive. PATIENTS: A total of 90048 injured patients admitted to all acute care hospitals in the state of Washington from 1991 through 1993 and discharged with at least 1 diagnosis coded in the International Classification of Diseases, Ninth Revision, Clinical Modification to indicate trauma. MAIN OUTCOME MEASURES: Death in the hospital and death within 30 days of hospital discharge. RESULTS: Among 1912 injured patients with in-hospital deaths, 825 death certificates (43%) listed a noninjury cause of death. The overall mortality rate at hospital discharge was 21.2 per 100000 hospitalized injured patients, and was 12.1 per 100000 for trauma deaths and 9.1 per 100000 for those designated as nontrauma deaths. Patients with trauma-related death designations were younger (mean age, 51.5 years vs 77.9 years), had shorter lengths of stay (median stay, 2 days vs 5 days), and sustained more severe injures (P<.001). Including the 1273 deaths that occurred within 30 days of hospital discharge increased rates for trauma-designated deaths to 14.1 per 100000 and increased rates for nontrauma-designated deaths to 21.3 per 100000. CONCLUSIONS: Hospital discharge death rates are incomplete measures of death frequency for injured patients. Designation of the cause of death, especially among older, hospitalized, injured patients often reflects preexisting medical conditions. Adequate assessment of mortality following trauma requires measurement of the frequency of death following hospital discharge.

Adolescent↗
PubMed1998

Echinacea-associated anaphylaxis.

A woman with atopy experienced anaphylaxis after taking, among other dietary supplements, a commercial extract of echinacea. Hypersensitivity was confirmed by skinprick and RAST testing. Regular ingestion of echinacea by up to 5% of surveyed patients with atopy, combined with detection of echinacea-binding IgE in atopic subjects (19% by skin testing; 20% with moderate to strong reactivity by RAST testing), raises the possibility of severe allergic reactions, even with first-time use, due to cross-reactivity with other structurally similar allergens. Patients with atopy should be cautioned about the risk of developing life-threatening reactions to complementary medicines, including echinacea.

Adult↗
PubMed1998

The utility of polyglycolic acid mesh for abdominal access in patients with necrotizing pancreatitis.

BACKGROUND: Necrotizing pancreatitis is a poorly understood process that has been treated by a variety of surgical approaches. Despite advances in operative interventions and critical care, this disease often requires prolonged resource allocation and continues to cause substantial morbidity, with mortality rates ranging from 11% to 40%. We report on our recent series of patients with necrotizing pancreatitis and our experience with the use of an absorbable mesh in a subset of these patients to facilitate their surgical care. STUDY DESIGN: From 1985 to 1994, 40 patients with culture-proved necrotizing pancreatitis underwent operative debridement and drainage. Surgical outcomes were compared among patients who underwent a single debridement and drainage, those requiring multiple procedures, and those having placement of polyglycolic acid mesh. RESULTS: The overall hospital mortality rate was 30%. The mean length of hospital stay was 35 days. The rate of infected pancreatic necrosis was 60%, with a mortality rate of 45% in patients having infected pancreatic tissue at surgery. Patients without infected pancreatic tissue at surgery had a mortality rate of 6% (p = 0.03). Eleven patients requiring multiple operations had placement of absorbable polyglycolic acid mesh. Clinic followup was possible in five of six survivors who underwent mesh closure. Abdominal-wall hernias developed in two patients and were repaired electively, and three patients had spontaneous closure by granulation without abdominal-wall hernias. The average number of operations for debridement and drainage was 2.5 (range, 1-15). Patients with limited pancreatic necrosis required a single operative debridement and drainage, and this was associated with improved outcomes. CONCLUSIONS: Necrotizing pancreatitis remains an important challenge in surgical care. It requires prolonged hospitalization, costly resources, and causes substantial morbidity and mortality. Our patients with infected pancreatic necrosis or clinical deterioration underwent open staged necrosectomy and debridement. Those patients requiring repeat laparotomy often had placement of polyglycolic acid mesh. This provided open drainage of the abdominal cavity and simplified further care by allowing easy abdominal access for repeat drainage procedures, often performed in the intensive care unit. These patients had a high rate of fistula formation, which may be decreased by changes in wound care. Polyglycolic acid mesh is a useful adjunct in the surgical care of selected patients with necrotizing pancreatitis.

Abdominal Muscles↗
PubMed1998

Surveyed opinion of American trauma surgeons in management of colon injuries.

BACKGROUND: Primary repair or resection and anastomosis of colon wounds have been advocated in many recent studies, but the proportion of trauma surgeons accepting these recommendations is unknown. OBJECTIVE: To determine the current preferences of American trauma surgeons for colon injury management. METHODS: Four hundred forty-nine members of the American Association for the Surgery of Trauma were surveyed regarding their preferred management of eight types of colon wounds among three options: diverting colostomy (DC), primary repair (PR), or resection and anastomosis (RA). The influence of selected patient factors and surgeons' characteristics on the choice of management was also surveyed. RESULTS: Seventy-three percent of surgeons completed the survey. Ninety-eight percent chose PR for at least one type of injury. Thirty percent never selected DC. High-velocity gunshot wound was the only injury for which the majority (54%) would perform DC. More than 55% of the surgeons favored RA when the isolated colon injury was a contusion with possible devascularization, laceration greater than 50% of the diameter, or transection. Surgeons who managed five or fewer colon wounds per year chose DC more frequently (p < 0.001) and PR less frequently (p < 0.001) than surgeons who managed six or more colon wounds per year. CONCLUSION: The prevailing opinion of trauma surgeons favors primary repair or resection of colon injuries, including anastomosis of unprepared bowel. Surgeons who manage fewer colon wounds prefer colostomy more frequently.

Adult↗
PubMed1998

Preferential benefit of implementation of a statewide trauma system in one of two adjacent states.

BACKGROUND: Implementation of Oregon's trauma system was associated with a reduction in the risk of death for hospitalized injured patients. An alternative explanation for improved outcome, however, is favorable concurrent temporal trends, e.g., new technologies and treatments. PATIENTS AND METHODS: To control for temporal trends, seriously injured hospitalized patients in Oregon and Washington were compared before either state had a trauma system (1985-1988) and when only the Oregon trauma system had been implemented (1990-1993). The study group consisted of hospitalized injured patients aged 16 to 79 years with one or more index injuries in six body regions, i.e., head, chest, spleen/liver, femur or pelvis fracture, and burns. Hospital discharge claims data were analyzed, converting International Classification of Diseases, Ninth Revision, Clinical Modification, discharge diagnosis codes to Abbreviated Injury Scale scores and Injury Severity Scores using a conversion algorithm. Multivariate logistic regression models were used to estimate the differential risk-adjusted odds of death in Oregon compared with Washington after adjustment for demographics, injury type, and injury severity. RESULTS: Findings indicated no difference in the risk-adjusted odds of death between Oregon and Washington while both states functioned under an ad hoc trauma system (1985-1988). A significant reduction in the risk of death, however, was noted in Oregon for patients with an index injury and an Injury Severity Score > 15 compared with Washington (adjusted odds ratio (OR) = 0.80, 95% confidence interval (CI) = 0.70-0.91) after trauma system implementation in Oregon (1990-1993). Specifically, reductions in the risk of death were demonstrated for patients with head injuries (adjusted OR = 0.70, 95% CI = 0.59-0.82) or liver/spleen injuries (adjusted OR = 0.73, 95% CI = 0.54-0.99). CONCLUSION: Assuming that the two states demonstrated similar concurrent temporal trends, the findings support the conclusion that improved outcomes among injured patients in Oregon may be attributed to the institution of a statewide trauma system.

Abbreviated Injury Scale↗
PubMed1998

Significance of peritoneal fluid as an isolated finding on abdominal computed tomographic scans in pediatric trauma patients.

BACKGROUND: Peritoneal fluid on abdominal computed tomographic (CT) scan in the absence of solid-organ injury suggests a bowel injury. We sought to determine the significance of peritoneal fluid as the sole finding on abdominal CT scans obtained to evaluate injured pediatric patients. METHODS: We performed a retrospective review of abdominal CT scans obtained during the initial survey of blunt trauma patients less than 19 years old during a 5-year period (1991-1995). All patients received intravenous and oral contrast agents. All CT scans were read by a staff radiologist. All CT scan results were retrospectively verified by one of the authors. RESULTS: Of the 259 scans, 157 (59%) were read as normal; 76 (31%) demonstrated solid-organ injury or pelvic fracture; 2 (1%) had pneumoperitoneum and 24 (9%) had peritoneal fluid as the only finding. Quantification of the fluid was done using a previously described method. Of the 16 patients with a small amount of fluid, only 2 (12%) required celiotomy. Of the eight patients with a moderate amount of fluid, four (50%) required celiotomy. At celiotomy, the six patients all had small-bowel injuries. No abdominal CT scan demonstrated extravasation of oral contrast. CONCLUSION: Intra-abdominal fluid as the sole finding on abdominal CT scan does not mandate immediate celiotomy in the bluntly injured pediatric patient. The patient with fluid in more than one location has a 50% chance of bowel injury. We also conclude that extravasated enteral contrast is rarely present to aid in the diagnosis of bowel injury in children.

Abdominal Injuries↗
PubMed1997

Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure.

OBJECTIVE: To determine whether prevention of the abdominal compartment syndrome after celiotomy for trauma justifies the use of absorbable mesh prosthesis closure in severely injured patients. DESIGN: Retrospective analysis of case series from July 1, 1989, to July 31, 1996. SETTING: University-based level I trauma center. PATIENTS: Seventy-three consecutive trauma patients requiring celiotomy who received absorbable mesh prosthesis closure and 73 control patients matched for injury severity and trauma type who received celiotomy without a mesh prosthesis closure. INTERVENTIONS: Absorbable mesh prosthesis closure was used in cases of excessive fascial tension, abdominal compartment syndrome, necrotizing fasciitis, traumatic defect, or planned reoperation. MAIN OUTCOME MEASURES: Demographics, Injury Severity Score, Abdominal Trauma Index, highest abdominal Abbreviated Injury Scale score, number of abdominal/pelvic injuries, highest head Abbreviated Injury Scale score, shock, indication for mesh closure, complications, number of operations and time required for closure, days in the intensive care unit, length of stay, and mortality were determined. The highest abdominal Abbreviated Injury Scale score was multiplied by the number of abdominal/pelvic injuries to calculate the abdominal pelvic trauma score. RESULTS: Group 1 consisted of 47 patients who received mesh at initial celiotomy, and group 2, 26 patients who received mesh at a subsequent celiotomy. These 2 groups were statistically similar in demographics, injury severity, and mortality. However, group 2 had a significantly higher incidence of postoperative abdominal compartment syndrome (35% vs 0%), necrotizing fasciitis (39% vs 0%), intra-abdominal abscess/peritonitis (35% vs 4%), and enterocutaneous fistula (23% vs 11%) compared with group 1 (P < .001). Group 1 patients with preoperative abdominal compartment syndrome had more abdominal/ pelvic injuries and higher abdominal trauma index than matched controls (P < .05). There was a trend toward higher abdominal pelvic trauma score in patients who developed abdominal compartment syndrome. The Pearson coefficient of correlation between the abdominal trauma index and the more easily calculated abdominal pelvic trauma score was 0.91 (P < .001). CONCLUSION: The use of absorbable mesh prosthesis closure in severely injured patients undergoing celiotomy was effective in treating and preventing the abdominal compartment syndrome.

Abdomen↗
PubMed1997

Specifications for calculation of risk-adjusted odds of death using trauma registry data.

BACKGROUND: Logistic regression models, with coefficients developed from normative populations, can be applied to a trauma registry cohort to predict the risk-adjusted frequency of death. Quality of care is judged based on differences between predicted and observed mortality frequency. The goal of these analyses was to determine if decedents who died in the emergency department had independent variables associated with risk of death identical to those who died after hospital admission. METHODS: This case-control study is based upon decedents in a trauma registry matched to survivors. Backward stepwise linear logistic regression models contained independent variables selected to reflect patients' status before treatment. RESULTS: Beta coefficients and independent variables selected for models of expired emergency department patients were different from those of hospital death patients. CONCLUSIONS: To achieve a more precise determination of risk-adjusted mortality for injured patients at a trauma center, two separate analyses are appropriate: death in emergency department and death after hospital admission.

Adolescent↗
PubMed1997

Influence of a statewide trauma system on pediatric hospitalization and outcome.

BACKGROUND: During the years 1987-1991, a statewide trauma system was implemented in Oregon (Ore) but not in Washington (Wash). Incidence of hospitalization, frequency of death and risk-adjusted odds of death for injured children (< 19 years) in the two adjacent states were compared for two time periods (1985-1987 and 1991-1993). METHODS: State populations of injured children (International Classification of Diseases, 9th Revision-Clinical Modification, code 800-959) were identified through a Hospital Discharge Index. Hospitals in counties with a population density < 50 persons/square mile were designated rural. Incidence rates are events/10,000 pediatric population per year. RESULTS: The pediatric population increased in both states (Ore: 687,000-758,000; Wash: 1,159,000-1,336,000). Incidence of hospitalization for all injured children in entire states declined (Ore: 66.5-38.5; Wash: 54-33); also in rural hospitals (Ore: 67.5-32; Wash: 48 to 31). Seriously injured children (score on the Injury Severity Scale > 15) had a lower incidence in 1991-1993 of admission to rural hospitals (Ore: 2.98; Wash: 2.82) compared with incidence for entire states (Ore: 4.61; Wash: 4.62); in 1985-1987 the incidence was not different. Furthermore risk adjusted odds of death for seriously injured children was significantly lower in Oregon than in Washington in the later time period. CONCLUSION: Both states show a similar temporal trend toward a declining frequency of death for children hospitalized with injuries. Injury prevention strategies appear to have reduced the number of serious injuries in both states. However, seriously injured children demonstrated a reduced risk of death in Oregon, consistent with benefit from a statewide trauma system.

Adolescent↗
PubMed1997

Impact of a statewide trauma system on rural emergency department patient assessment documentation. OHSU Rural Trauma Research Group.

OBJECTIVE: To determine the association of rural ED patient assessment documentation with state trauma system implementation, hospital trauma categorization level (i.e., Level-3 vs Level-4), injury diagnosis, and patient demographics. METHODS: A pre- vs post-system implementation (historical control) analysis of trauma documentation was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. The medical records of patients with specific index diagnoses in 4 anatomic regions (head, chest, liver/spleen, and femur/open-tibia) were reviewed for 3-year periods before statewide trauma system implementation and after hospital categorization. Vital sign, % inspired O2, and O2 saturation determinations were identified relative to the first and the last vital signs documented on the ED record. If not documented in the medical chart within 5 minutes of the first or last ED vital sign assessment, these measurements were considered missing. Separately, neurologic documentation (initial and final) also was sought for patients meeting criteria for an index head injury. RESULTS: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had a head injury, 34% had a chest injury, 23% had a femur/open-tibia injury, and 12% had a spleen/liver injury. There were 142 (13%) patients with an injury in > 1 index area. Except for initial systolic blood pressure, documentation of all other initial and final patient vital signs increased significantly (p < 0.05). Documentation of the Glasgow Coma Scale score (initial and final; p = 0.0001) and a final pupil examination on head-injured patients (p = 0.025) also increased. The effects of hospital level, injury diagnosis, and patient demographics on documentation rate were minimal. CONCLUSION: The study found overall improved ED documentation of trauma patient status in association with implementation of a statewide trauma system. This improvement in documentation suggests an enhanced process of care with trauma system participation.

Adolescent↗
PubMed1997

The effects of femoral intramedullary reaming on pulmonary function in a sheep lung model.

Two methods of intramedullary fixation of fractures of the middle of the femoral shaft were evaluated in a sheep model to determine the effect of femoral reaming on pulmonary function. The effect of a modified reamer was also studied. A second experiment with the same model was performed to evaluate the relationship between embolization and pulmonary dysfunction. This experiment involved two groups of sheep--those with normal lungs and those with contused lungs--divided into subgroups--those that had nailing with reaming and those that had nailing without reaming. Intracardiac ultrasound was used to measure the magnitude and duration of transvenous particulate embolization during the operations. Both experiments involved hemodynamic monitoring during and after the nailing. The pulmonary tissue was examined histologically after the animals were killed. The hemodynamic monitoring revealed only a transient increase in pulmonary vascular resistance in the animals that had femoral nailing with reaming in both experiments. The modified reamer had no effect on the pulmonary response. Histological analysis of pulmonary tissue demonstrated a significant increase in the number of fat emboli in both the animals that had nailing with reaming and the animals that had nailing without reaming compared with the control animals. Intravascular ultrasound revealed that the operative maneuver associated with the greatest number of emboli was opening of the intramedullary canal with the awl. The first two passes of the reamer produced more emboli and embolism of longer duration than did the later passes. Pulmonary confusion did not increase the risk of pulmonary dysfunction due to intramedullary nailing in this model.

Animals↗
PubMed1997

Rural hospital transfer patterns before and after implementation of a statewide trauma system. OHSU Rural Trauma Research Group.

OBJECTIVE: To evaluate trauma transfer practices in rural Oregon before and after implementation of a statewide trauma system. METHODS: A pre- vs post-system implementation (historical control) analysis of trauma transfer practices was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. Medical records of patients with specific index injury diagnoses in 4 anatomic regions (head, chest, liver/ spleen, and femur/open-tibia) were reviewed for a 3-year period before statewide trauma system implementation and 3 years after hospital trauma designation. RESULTS: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had head injuries, 34% had chest injuries, 23% had femur/open-tibia injuries, and 12% had spleen/liver injuries. There were 142 (13%) patients with an injury in > 1 index area. After trauma system implementation, there was a significant increase in the proportion of ED trauma patients transferred from Level-4 trauma hospitals (32% vs 68%, p < 0.001), with a corresponding decrease in the number of hospital admissions to these facilities (63% to 29%, p < 0.001). Significant increases in the proportion transferred from Level-4 trauma hospital EDs were noted for all index injury categories (p < 0.001). Trauma patients presenting to Level-4 EDs were significantly more likely to be transferred to Level-2 facilities (66% vs 82%, p = 0.030), while patients at Level-3 facilities were significantly more likely to be transferred to Level-1 centers (2% vs 14%, p = 0.002) following trauma system implementation. Multiple logistic regression modeling indicated that implementation of the statewide trauma system was an independent predictor of rural trauma patient transfer from Level-4 hospitals, while transfers from Level-3 facilities were dependent on type of injury. CONCLUSION: Implementation of the Oregon statewide trauma system was associated with a redistribution of rural trauma patients to trauma hospitals with greater therapeutic resources.

Emergency Medical Services↗
PubMed1996

Blunt brain injury activates the coagulation process.

OBJECTIVE: To measure the prevalence of and characterize coagulopathy in patients with blunt brain injury. DESIGN: Retrospective observation study based on review of medical records. SETTING: Acutely injured patients admitted to a level I trauma center. PATIENTS: One hundred fifty-nine patients with evidence of blunt head trauma who had computed tomography of the brain during initial evaluation and a coagulopathy score assigned based on 5 laboratory tests: platelet count, prothrombin time, partial thromboplastin time, fibrinogen level, and D-dimer level. The disseminated intravascular coagulation score ranged from 0 (no coagulopathy) to 15 (severe coagulopathy). Only individuals with intracranial injury based on computed tomography of the brain were designated as brain injured. MAIN OUTCOME MEASURES: Presence of coagulopathy, progression of brain injury, and death. RESULTS: Among the 91 patients with brain injury, 41% had coagulopathy (disseminated intravascular coagulation score > or = 5). Of the 68 patients without brain injury, 25% had coagulopathy. The patients with brain injury who developed profound depletion of fibrinogen did so within 4 hours of injury. There were 28 deaths (26 in the group with brain injury and 2 in the group without brain injury). Among patients with brain injury, those with coagulopathy more frequently died (P < .05 by chi 2 analysis). Patients with brain injury and coagulopathy deteriorated more frequently based on computed tomography criteria. CONCLUSIONS: After blunt brain injury, a disseminated intravascular coagulation syndrome can lead to consumptive coagulopathy that is associated with a higher frequency of death. The syndrome develops within 1 to 4 hours after injury. Therapeutic interventions need to be implemented immediately to be effective.

Adult↗
PubMed1996

Ventilatory management of pulmonary contusion patients.

BACKGROUND: The goal of this study was to evaluate two modes of mechanical ventilation in patients with pulmonary contusion: pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV). METHODS: One hundred and thirty-five patients with pulmonary contusion, defined as an infiltrate on admission chest x-ray and hypoxemia, were treated over 45 months; 59 patients who required more than 48 hours of mechanical ventilation were initially managed with VCV. RESULTS: Twenty patients were converted from VCV to PCV when pulmonary function deteriorated. With PCV, peak inspiratory pressure decreased from 49 +/- 1 to 31 +/- 1 cm H2O, the alveolar-arterial oxygen difference decreased from 491 +/- 36 mm Hg to 300 +/- 36 mm Hg. These findings were significantly different (P < 0.05, by Student's paired t-test). Twenty patients managed with PCV had equivalent duration of mechanical ventilation and days in intensive care units to 39 patients with less pulmonary dysfunction managed with VCV. None of the 10 patients who died expired from pulmonary failure. CONCLUSIONS: PCV is an alternative mode to VCV in patients with poorly compliant lungs after pulmonary contusion.

Adolescent↗